Innovation summary

In South Africa, about one third of pregnant women experience a common mental disorder. Due in part to the shortage of mental health specialists, many individuals do not receive the care they require.

The goal of the Perinatal Mental Health Project (PMHP) is to integrate mental health care into routine antenatal and postnatal health care to address the shortage of human resources and bridge the treatment gap for perinatal mental disorders.

The innovation consists of a collaborative stepped-care approach and task-sharing strategies:

Women are screened for psychological distress at their first antenatal booking

Women with three or more risk factors and/or those that screen positive for psychological distress are referred to counseling sessions delivered by trained, non-specialized health workers

Counselors refer severe cases to the on-site psychiatrist

Impact summary

Over 21,000 pregnant women screened for psychological distress between 2002 and 2013

"Maternity nursing staff have successfully managed to incorporate mental health screening into routine procedures reporting high levels of acceptability of this integration."

Perinatal Mental Health Project

Innovation details

The Perinatal Mental Health Project (PMHP) uses a stepped-care model and operates as below at its primary service site:

Screening

At their first antenatal booking at the maternity unit, women are screened for psychological distress and for risk factors for common perinatal mental disorders. Screening is self-administered in private and scored by nurses, and available in three local languages (English, Afrikaans and isiXhosa) and in French.

Referral

Pregnant women with psychological distress and/or at least three risk factors are offered referral to an on-site counselor for individual, face-to face counseling, which coincides with their antenatal visits. Where appropriate, counselors can refer women to a psychiatrist who attends the clinic twice a month, and to on-site services, such as HIV/AIDS peer counselors, social workers etc.

Counselling

Counseling is provided by non-specialized health workers: sessions are client-centered and include techniques such as containment, psycho-education and problem-solving. At 6-10 weeks, counselors conduct telephonic or face-to-face assessments to evaluate women’s mood and whether further counseling is necessary. Women can receive counseling for up to one year postpartum.

In order to implement this model successfully, PMHP provides the following services:

Monitoring and supervision

All counselors receive weekly, individual supervision by the clinical services coordinator, a clinical psychologist, and attend a group meeting bi-monthly to debrief and receive on-going education from the clinical services coordinator.

Training

PMHP also provides training and workshops to staff in order to attend to health workers’ emotional well-being, increase awareness of common perinatal mental disorders among health workers and equip health workers with empathic engagement skills.

Research and advocacy

PMHP operates complementary research and advocacy programs which act to refine and promote scale up of the service.

Key drivers

Training and support

Regular training updates with maternity staff ensure that health workers are aware of, and understand the importance of PMHP’s service facilitating the integration of the service into maternal care. Provided continuous training, supervision and support to non-specialist health workers to: (1) manage the high case load generated in low-resource settings and (2) avoid burnout and ensure the sustainability and quality of maternal mental health care provided.

Effective case management

Established protocol and referral systems enable more effective case management. The availability of an on-site counselor, and consolidating links with organisations in the community, strengthens the referral system and allows for more comprehensive care for distressed women.

Monitoring and evaluation

Regular monitoring and evaluation of screening and counseling procedures are essential for quality control, understanding the patterns of service use and identifying barriers to accessing mental health services.

Challenges

Overwhelmed nurses

Multi-language counseling

Mothers from a variety of cultural backgrounds called for multi-language counseling: English, Afrikaans, isiXhosa, and French for the large proportion of francophone refugees.

Limited availability of screening tool

Limited availability of feasible and acceptable screening tools for maternal mental disorders. PMHP uses the Edinburgh Postnatal Depression Scale. Though validated in South Africa, it is too cumbersome for low-resource settings. PMHP is developing a shorter tool which should be more feasibly integrated into the primary care setting.

Continuation

PMHP has extended its service to two other community maternity units in Cape Town. As all of the current PMHP sites are situated in urban areas, there is a need to field test the service in a rural site, where fewer resources and different challenges exist.

The literacy rate is high in South Africa (93%), compared to other African countries (e.g. 40% in Ethiopia; 73% in Uganda), where self-administered screening may not be feasible. A shorter screening tool, such as the one PMHP is currently developing, could be more pragmatic for health workers to administer during their routine history-taking. The tool will be field tested in a range of settings including New Zealand, India, UK and USA.

Evaluation methods

The Perinatal Mental Health Project (PMHP) has a structured and consistent monitoring and evaluation (M&E) framework, with screening and service delivery data collated and reported monthly to the clinical services coordinator and the PMHP project coordinator. The M&E framework:

Facilitates the identification of clients’ characteristics, risk profiles and related care requirements, which can then be addressed effectively

Allows an assessment of the PMHP service’s impact and delivery and the barriers to accepting and attending counseling services, so that these can be overcome

The 6-8 week postnatal assessment, which also elicits information about the women’s birthing experience, adjustment to life with the baby and their experience of counseling, provides a good opportunity to:

Evaluate women’s mood and functioning postnatally, compared to that at screening

Assess whether the women’s presenting problems have improved

A study protocol to formally assess the effectiveness of the counseling intervention is currently underway, and should receive approval to start early in 2014

Cost of implementation

The full cost to provide maternal mental health care to one woman is $19.50 USD per year. This includes:

As many counseling sessions as she needs (3 on average)

The counselor’s liaison work with psychiatric services and social support agencies

Postnatal follow-up care

In comparison, the average rate of private sector psychotherapy is $70 USD per hour for one individual counseling session alone.

In low-resource settings, where women can face many barriers to accessing health care, providing integrated mental health care at the same time and same place as routine maternity and well-baby care minimizes travel costs, time away from employment and child-care responsibilities. Thus, PMHP’s counseling intervention, which uses existing services and resources, achieves better service uptake with minimal extra costs.

Impact details

Since inception (2002) to July 2013, over the three service sites, PMHP has:

Screened nearly 22,000 pregnant women for psychological distress

Counseled over 3,700 women

Provided over 8,400 individual counseling sessions

Provided psychiatric services to approximately 130 women

Ongoing monitoring and evaluation of the postnatal follow-up assessment shows positive outcomes for women who are counseled:

Problems relating to support from partners or family and the social environment are typically the most difficult to resolve, yet around 85% report improvement following counseling

90% of primary and secondary problems presented before counseling improve, including 50-60% which are either “much improved” or “resolved”

Hi Jake, this is Grace from the MHIN team. PMHP have kindly provided further information about the screening tool on this resource page, which also links to a video about the tool's development <http://mhinnovation.net/resources/screening-common-perinatal-mental-disorders-south-africa#.U-sutfldV8E>. If you would like to get in touch with PMHP directly, you can also click the "Email" link just under the PMHP logo on this Innovation page. You can look forward to a blog from PMHP about this work as well, which we will be posting soon, so stay tuned to the Community section for more. Enjoy!